The client with gastroesophageal reflux disease (GERD) is receiving dietary modification education from the nurse. Which statement by the client indicates a need for further teaching?
- A. I will avoid eating large meals before bedtime.
- B. I will limit coffee consumption to the morning hours.
- C. I will elevate the head of my bed while sleeping.
- D. I will avoid spicy and acidic foods.
Correct Answer: B
Rationale: The correct answer is B. Clients with GERD should avoid coffee as it can relax the lower esophageal sphincter and exacerbate symptoms. Limiting coffee consumption to the morning hours may not be sufficient, as coffee can still contribute to GERD symptoms throughout the day. Choices A, C, and D are all appropriate strategies for managing GERD symptoms. Avoiding large meals before bedtime, elevating the head of the bed while sleeping, and steering clear of spicy and acidic foods are all recommended practices to help alleviate GERD symptoms. Therefore, the client's statement in option B indicates a need for further teaching to completely address dietary modifications for managing GERD.
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A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?
- A. Remove clocks from the client's room
- B. Use full-length side rails on the client's bed
- C. Check on the client frequently while they are in the restroom
- D. Encourage physical activity throughout the day to expend energy
Correct Answer: D
Rationale: Encouraging physical activity throughout the day is an effective way to manage confusion in clients and reduce the need for restraints. Physical activity helps in expending energy, promoting circulation, and improving overall well-being. Removing clocks from the client's room (choice A) may not directly address the issue of confusion or reduce the need for restraints. Using full-length side rails on the client's bed (choice B) can actually increase the risk of entrapment and should be avoided. Checking on the client frequently while they are in the restroom (choice C) is important for monitoring safety but may not directly address the underlying issue of confusion and the need for restraints.
A client with chronic kidney disease is experiencing hyperkalemia. Which medication should the LPN/LVN anticipate being prescribed to lower the client's potassium level?
- A. Furosemide (Lasix)
- B. Sodium polystyrene sulfonate (Kayexalate)
- C. Calcium gluconate
- D. Albuterol (Proventil)
Correct Answer: B
Rationale: The correct answer is B: Sodium polystyrene sulfonate (Kayexalate). Kayexalate is commonly used to lower potassium levels in clients with hyperkalemia by exchanging sodium ions for potassium ions in the large intestine, leading to the elimination of excess potassium from the body. Choice A, Furosemide (Lasix), is a loop diuretic that helps with fluid retention but does not directly lower potassium levels. Choice C, Calcium gluconate, is used to treat calcium deficiencies and does not impact potassium levels. Choice D, Albuterol (Proventil), is a bronchodilator used to treat respiratory conditions and does not affect potassium levels. Therefore, the LPN/LVN should anticipate the prescription of Kayexalate to address the client's hyperkalemia.
A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The professional should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 107 mL/hr
- B. 120 mL/hr
- C. 95 mL/hr
- D. 100 mL/hr
Correct Answer: A
Rationale: To calculate the infusion rate, divide the total volume (750 mL) by the total time (7 hr). 750 · 7 ≈ 107 mL/hr. Choice A is correct because it accurately calculates the infusion rate based on the total volume and time. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate in this scenario.
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
- A. Carefully remove the gloves and follow with hand hygiene
- B. Continue with the procedure and clean hands later
- C. Remove the gloves, wash hands, and start over
- D. Use hand sanitizer and continue the procedure
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.
A client reports having insomnia. Which of the following interventions is appropriate for the nurse to recommend?
- A. Exercise 1 hour before bedtime.
- B. Eat a light carbohydrate snack before bedtime.
- C. Drink a cup of hot cocoa before bedtime.
- D. Take a 30-minute nap daily.
Correct Answer: B
Rationale: Eating a light carbohydrate snack before bedtime is a suitable intervention for insomnia because it can help stabilize blood sugar levels and promote sleep. Exercising close to bedtime may actually disrupt sleep patterns due to increased alertness and body temperature. Drinking hot cocoa before bedtime, which contains caffeine, may interfere with falling asleep. Taking a nap during the day can make it harder to fall asleep at night and may worsen insomnia. Therefore, the best recommendation among the choices provided is to eat a light carbohydrate snack before bedtime.